Malina-Altzinger et al.

International Journal of Implant Dentistry (2015) 1:17

DOI 10.1186/s40729-015-0015-1

RESEARCH

Open Access

Evaluation of the maxillary sinus in

panoramic radiographya comparative study
Johann Malina-Altzinger1* , Georg Damerau2, Klaus W Grtz3 and PD Bernd Stadlinger2

Abstract
Background: The aim of this study was to evaluate the validity and the inter- and intra-examiner reliability of
panoramic-radiograph-driven findings of different maxillary sinus anatomic variations and pathologies, which had
initially been prediagnosed by cone beam computed tomography (CBCT).
Methods: After pairs of two-dimensional (2D) panoramic and three-dimensional (3D) CBCT images of patients having
received treatment at the outpatient department had been screened, the predefinition of 54 selected maxillary sinus
conditions was initially performed on CBCT images by two blinded consultants individually using a questionnaire that
defined ten different clinically relevant findings. Using the identic questionnaire, these consultants performed the
evaluation of the panoramic radiographs at a later time point. The results were analyzed for inter-imaging differences
in the evaluation of the maxillary sinus between 2D and 3D imaging methods. Additionally, two resident groups
(first year and last year of training) performed two diagnostic runs of the panoramic radiographs and results were
analyzed for inter- and intra-observer reliability.
Results: There is a moderate risk for false diagnosis of findings of the maxillary sinus if only panoramic radiography is
used. Based on the ten predefined conditions, solely maxillary bone cysts penetrating into the sinus were frequently
detected differently comparing 2D to 3D diagnostics. Additionally, on panoramic radiographs, the inter-observer
comparison demonstrated that basal septa were significantly often rated differently and the intra-observer comparison
showed a significant lack in reliability in detecting maxillary bone cysts penetrating into the sinus.
Conclusions: Panoramic radiography provides the most information on the maxillary sinus, and it may be an adequate
imaging method. However, particular findings of the maxillary sinus in panoramic imaging may be based on a rather
examiner-dependent assessment. Therefore, a persistent and precise evaluation of specific conditions of the maxillary
sinus may only be possible using CBCT because it provides additional information compared to panoramic radiography.
This might be relevant for consecutive surgical procedures; consequently, we recommend CBCT if a precise preoperative
evaluation is mandatory. However, higher radiation dose and costs of 3D imaging need to be considered.
Keywords: Panoramic radiography; Cone beam computed tomography; Maxillary sinus; Inter-imaging method
differences; Inter-examiner reliability; Intra-examiner reliability

Background
The development of two-dimensional (2D) panoramic
imaging techniques began in the first half of the 20th
century, but the first device applying this technology was
only described in 1959 [1]. Since then, this radiographic
technique has steadily been improved and has become a
standard diagnostic tool in a clinicians daily practice. In
parallel, cone beam computed tomography (CBCT), first
* Correspondence: Johann.malina-altzinger@insel.ch
1
Clinic of Cranio-Maxillofacial Surgery, University Hospital of Bern,
Freiburgstrasse 4, 3010 Bern, Switzerland
Full list of author information is available at the end of the article

described in 1982 [2], was introduced as a tool for dental

and maxillofacial diagnostics.
The advantages of three-dimensional (3D) CBCT over
2D conventional panoramic tomography include an excellent imaging quality of high-contrast structures like
the maxillofacial bone anatomy, no geometric distortion,
and no superimposition of surrounding anatomic structures [3]. The advantages of panoramic radiography, on
the other hand, are comparatively low-radiation doses,
its general availability, and the comparatively low costs.
Further, it is especially useful in the initial diagnostic

2015 Malina-Altzinger et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution
License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any
medium, provided the original work is properly credited.

Malina-Altzinger et al. International Journal of Implant Dentistry (2015) 1:17

phase of implant planning because it relates information

on both dental arches, the inferior alveolar canals, and
the maxillary sinuses to its pathologic conditions [4].
However, limitations include the lack of visualization of
structures like the bucco-lingual ridge pattern and the
visual loss of cortical plates or undulating concavities
[5]; moreover, the fact that more than 80 % of measurements from the crest of the residual alveolar ridge to the
inferior alveolar canal have errors of more than 1 mm
renders panoramic radiography unsuitable as a single
imaging source for dental-implant site assessment [4].
Furthermore, it is well known that an average magnification factor of 1.25 can be expected in panoramic radiographs. This demands calibration of the image with the
help of a defined reference device when determining the
appropriate implant size [6].
Precise assessment of the maxillary sinus is mandatory
when planning a lateral or internal sinus floor elevation
[7, 8]. It has been claimed that, besides clinical examination, evaluation of the maxillary sinuses is possible by
panoramic radiography [9] and CBCT [7, 10]. Though it
is known that millions of sinus lift operations were performed with panoramic radiographs without any problems, especially due to the superimposition of different
structures, precise assessment of a maxillary sinus finding is difficult in 2D panoramic radiography [11]. This
difficulty implies that, as a clinical consequence, patients
are often referred to specialists on the basis of a suspected maxillary pathology visualized on a panoramic
image. This further requires a CBCT, and the question
arises whether a primary CBCT should be performed in
cases of maxillary sinus diagnostics instead of an initial
panoramic radiography. Moreover, the inter- and intraexaminer variation in the interpretation of 2D radiographs may exceed the variation in imaging techniques
and diagnostic yield [12], leading to a rather examinerdependent assessment of panoramic images.
Therefore, the present study had three aims: the evaluation of the validity (1), the inter- (2), and the intraexaminer (3) reliability of panoramic-radiograph-driven
findings of different maxillary sinus conditions which
had initially been prediagnosed in CBCT images.

Methods
The study protocol was approved by the Eidgenssische
Expertenkommission fr das Berufsgeheimnis in der
medizinischen Forschung (Federal expert committee for
professional confidentiality in medical research, BAG
035.0001-125/196). All patients have consented to provide their data for research and publication. Prior to this
study, a statistical study design was performed, and in a
retrospective approach, radiographic images of patients
having received treatment at the outpatient department
of the Clinic of Cranio-Maxillofacial and Oral Surgery at

Page 2 of 7

the University of Zurich were screened. Inclusion criteria

were patients having received 2D panoramic radiographs
(Cranex, Soredex, Tuusula, Finland) and 3D CBCT
(KaVo 3D eXam, Biberach, Germany) showing the maxillary sinus without any surgical procedure in between
the two examinations (mean 8.6 days, SD 21 days). Subsequently, possible clinically relevant anatomic variations
and pathologies of the maxillary sinus were predefined
(nine findings, one unimpaired condition) (Table 1) from
a surgical point of view. Twenty-eight patients were selected (63 % males, 37 % females, mean age 47.8 years,
range: 2085 years) according to the conditions shown
in Table 1, corresponding to a total amount of 56 maxillary sinuses (one per side).
All radiographic images were anonymized and analyzed using the OsiriX Imaging software (version 5.0.2)
and a monitor with a display resolution of 1680
1050 pixel. Image manipulation through change of
brightness, zoom in and out, and rotation was used
when needed. No time limit was appropriated, and all
observations were performed in the same room under
comparable light conditions. Findings of the maxillary
sinus were purely based on radiographic appearance
without using any other additional clinical or histological
information. A questionnaire served for recording the
diagnoses (Table 1).
The predefinition of maxillary sinus conditions was
initially performed on 3D CBCT images by two consultants in a separate evaluation using the questionnaire.
The following reconstruction parameters in all three dimensions (sagittal, coronal, axial) were used: voxel edge
length 0.4 0.4 0.4 mm, slice thickness 1 mm. The
two assessors were blindeddisagreement was solved by
discussion.
Evaluation of inter-imaging technique differences

The CBCT assessment served as a reference group for

later 2D panoramic image diagnostics which were performed separately by the same two consultants more

Table 1 Predefined findings of the maxillary sinus

1.

Complete opacity

2.

Basal opacity

3.

Foreign body

4.

Oro-antral communication

5.

Basal septum

6.

Polypoid mucosal thickening

7.

Maxillary bone cyst penetrating into the sinus

8.

Fluid level

9.

Status post sinus lift

10.

No finding

Malina-Altzinger et al. International Journal of Implant Dentistry (2015) 1:17

than 6 months after predefinition on CBCT images. An

identical questionnaire was used for both 3D and later
2D diagnostics. Inter-imaging technique differences in
evaluating the maxillary sinus with 2D or 3D imaging
method were analyzed with regard to false-positive and
false-negative decisions.
Evaluation of the inter-observer reliability

Using the same questionnaire, four blinded residents

separately performed the evaluation of the 2D panoramic radiographstwo in the first year and two in
the last year of training. Agreement between these
two rating groups in detecting findings in the maxillary sinus was analyzed for calculating inter-observer
reliability.
Evaluation of the intra-observer reliability

After more than 4 weeks, the same residents newly

evaluated all maxillary sinuses on 2D panoramic images.
Reassessment served for the calculation of the intraobserver reliability, which means individual agreement
between the two elevation runs.
The results were further evaluated with regard to the
prevalence of radiographic findings in the maxillary
sinus.
Data analyses and statistical methods

Data was recorded using Excel 2013 (Microsoft) and analyzed using IBM SPSS Statistics for Macintosh, Verion 22.0
(Armonk, NY: IBM Corp.). Collected data was analyzed
to demonstrate degree of agreement using the following statistical tests: logistic regression was used to estimate odds ratios. p values were calculated using a chisquared test. Kappa coefficient and McNemars test
were used for evaluating the reliability between the
two consultants analyzing the CBCT scans. Calculated
p values were considered significant for values <0.05.
Descriptive statistics computed means and standard
deviation for quantitative variables as well as absolute
and relative frequencies for qualitative variables.

Results
This study analyzed comparative and descriptive data for
the evaluation of the maxillary sinus. Significant differences in the detection of ten predefined findings between 2D and 3D imaging methods were calculated.
Furthermore, the degree of agreement in detecting the
ten conditions on the panoramic radiographs was
measured between different observers and within the
same observer. The radiographic images of 28 patients
(56 maxillary sinuses, 1 per side) were examined. One
patient had to be excluded from the study as the
radiographic finding on the CBCT did not clearly
match any of the predefined ten conditions.

Page 3 of 7

Differences between CBCT- and panoramic-radiographdriven evaluations of the maxillary sinus

As illustrated by Table 2, the results of the present study

demonstrate that in panoramic-radiograph-driven
diagnosis a no finding was selected in a quite similar way as if CBCT was used (p = 0.803, odds ratio
(OR) = 1.220). The difference between the two imaging methods was significant solely for maxillary
bone cyst penetrating into the sinus (p = 0.032). The
estimated OR of this specific finding was significantly
lower than 1 (OR = 0.275). No significant differences
between 2D and 3D imaging methods were found for
the detection of a complete opacity (p = 0.998), a basal opacity (p = 0.714), a foreign body (p = 0.571), an oro-antral
communication (p = 0.998), a basal septum (p = 0.911),
a polypoid mucosal thickening (0.123), a fluid level
(p = 0.253), and a status post sinus lift (p = 0.998)
(Table 2; Fig. 1).
Inter-observer differences

Good inter-observer reliability [13] between the two

consultants analyzing the CBCT scans was confirmed by
Kappa coefficient (0.7) and McNemars test (p > 0.05).
The comparison of the two resident groups (first-year,
last-year) examining 2D panoramic images showed that
basal septa were significantly often rated differently by
these two groups (p = 0.004, OR = 0.542). Further, it was
shown that there is a significant good inter-observer
agreement in detecting complete opacities (p < 0.001,
OR = 6.133) (Table 3; Fig. 2).
Intra-observer reliability

The intra-observer comparison showed that assessors of

panoramic radiographs were largely reliable considering
Table 2 Comparison of panoramic radiography and CBCT in
detecting ten different conditions of maxillary sinus
p

OR

Complete shadow

0.998

Basal shadow

0.714

0.822

Foreign body

0.571

1.831

Oro-antral communication

0.998

Basal septum

0.911

0.945

Polypoid mucosal thickening

0.123

0.376

Maxillary bone cyst penetrating into the sinus

0.032*

0.275

Fluid level

0.253

0.238

Status post sinus lift

0.998

No finding

0.803

1.22

Shown p values define the degree of agreement

a
Describes an odds ratio close to zero or infinity due to numerical problems
* p < 0.05

Malina-Altzinger et al. International Journal of Implant Dentistry (2015) 1:17

Page 4 of 7

Fig. 1 Radiographic findings of patient 26: basal opacity, maxillary bone cyst penetrating into the sinus; a panoramic radiography (Soredex, Cranex);
bd CBCT images (KaVo 3D eXam): coronal plane (b); panoramic reconstruction view (c); CBCT sagittal plane, left sinus (d)

the two evaluation runs of the same 2D panoramic

images with a 4-week interval in between. The analysis
indicated a significant lack of reliability (p = 0.044,
OR = 0.331) in diagnosing maxillary bone cysts penetrating into the sinus (Table 3).

Prevalence of findings

On the basis of 54 evaluated maxillary sinuses, the most

frequent radiographic findings in CBCT were basal septa
(54 %), followed by basal opacities (43 %), and foreign
bodies (15 %) (Fig. 3).

Table 3 Agreement in evaluating the maxillary sinus on

panoramic images
Inter-examiner

Intra-examiner

OR

OR

Complete shadow

<0.001*

6.133

0.549

1.387

Basal shadow

0.441

1.186

0.621

0.806

Foreign body

0.596

1.207

0.991

0.993

Oro-antral communication

0.842

1.083

0.432

0.547

Basal septum

0.004*

0.542

0.375

0.704

Polypoid mucosal thickening

0.052

1.748

0.060

0.404

Maxillary bone cyst penetrating

into the sinus

0.628

0.855

0.044*

0.331

Fluid level

0.653

1.515

0.999

0.000

Status post sinus lift

1.000

1.000

0.696

0.765

No finding

0.511

0.866

0.280

0.562

Inter-examiner describes agreement between two rating groups (first-year and

last-year residents) and intra-examiner describes individual agreement between
two evaluation runs. Shown p values define the degree of agreement
* p < 0.05

Discussion
The purpose of this study was to analyze the validity of
different anatomic variations and pathologies of the
maxillary sinus found in 2D panoramic radiography by
comparing them to those initially detected on CBCT images. Additional aims were the evaluation of inter- and
intra-examiner differences on panoramic-radiographdriven evaluation of the maxillary sinus.
Differences between CBCT- and panoramic-radiographdriven evaluations of the maxillary sinus

There is a moderate risk for false diagnosis of the maxillary sinus if only panoramic radiography rather than
CBCT is used. In the present study, comparing 2D to
3D imaging, solely maxillary bone cysts penetrating into
the sinus were frequently detected differently. MaestreFerrin et al. compared the efficacy of panoramic radiography, computed tomography (CT), and 3D CT in the
diagnosis of mucosal thickening, mucous cysts, or
complete opacity when using implant-planning software
and showed that panoramic radiography was comparatively inferior [14]. Maestre-Ferrin et al. [14, 15] also
showed that panoramic radiography led to false-positive
and false-negative findings in the visualization of maxillary sinus septa in almost half of their cases, and Krenmair
et al. [16] observed the same inaccuracy of panoramic radiography in detecting antral sinus septa in 13 out of 61
cases. Our study demonstrated no significant differences
between 2D and 3D imaging methods in the detection of
basal septa.
Inter-observer reliability

The inter-observer disagreement between the two resident groups (first-year vs. last-year residents) examining

Malina-Altzinger et al. International Journal of Implant Dentistry (2015) 1:17

Page 5 of 7

Fig. 2 Radiographic findings of patient 19: oro-antral communication, basal opacity, basal septa; a panoramic radiography (Soredex, Cranex);
bd CBCT images (KaVo 3D eXam): coronal plane (b); panoramic reconstruction view (c); CBCT sagittal plane, right sinus (d)

2D panoramic images was significant in the detection of

the basal septa. As mentioned above, Maestre-Ferrin
et al. have already indicated that panoramic radiography
is insufficient for the detection of sinus septa [15], which
complements to Shahbazian et al.s finding that even
though panoramic radiography provides a broad view of
the sinus floor, it is unsuitable for detecting small lesions, due to low spatial resolution [11]. A similar observation was obtained by Dreiseidler et al. who confirmed
superior visualization of all important high-contrast
structures for CBCT compared to panoramic radiography with a focus on presurgical implant planning [17].
Intra-observer reliability

There was only little intra-observer variation. The literature shows that the intra- and inter-examiner variation
in the interpretation of radiographs may exceed the
variation of imaging techniques and diagnostic yield
[12, 18, 19]. That some variations may not be eliminated

60%
50%
40%
30%
20%
10%
0%

Fig. 3 Descriptive illustration of 54 evaluated maxillary sinuses

despite observer training has already been indicated by

Kullman et al. [20]. Their study analyzed inter- and
intra-observer differences in assessing panoramic radiographs with regard to radiographic bone height at two
assessments several weeks apart. Both outcomes of two
observers were described as reliable but not excellent
though both raters were experienced.
One limitation of the latter and also of the present
study may be the relatively small number of raters. Another limitation of this study may be the prevalence
imbalance of different findings in the maxillary sinus
resulting in a negative impact on our statistical calculation. This might include not only the low prevalence of
maxillary bone cysts penetrating into the sinus but also
the high prevalence of basal septa, an imbalance former
studies have already demonstrated [15, 21, 22].
An explanation for our reported findings may be that,
due to the superimposition of different structures, low
spatial resolution and visual loss of cortical plates or

Malina-Altzinger et al. International Journal of Implant Dentistry (2015) 1:17

undulating concavities, precise evaluation of a maxillary

sinus finding is difficult in 2D panoramic radiography
[5, 11]. Moreover, this difficulty might express that, as
a consequence, the shown inter- and intra-observer
variation in the interpretation of 2D radiographs may
exceed the diagnostic yield [12].
Undiagnosed sinus conditions may be associated with
chronic orofacial pain that is one of the most common
reasons why patients consult physicians [23]. Moreover,
precise assessment of the maxillary sinus by obtaining
information on bone characteristics, on condition of
Schneiderian membrane, on the presence of septa, and
on the lateral sinus wall is mandatory prior to any lateral
or internal sinus floor elevation [7, 8]. Currently, different radiographic means are used for preoperative tooth
and bone-site and implant-site assessment. Clinicians
commonly use 2D or 3D radiography. Both options
imply advantages and disadvantages [4]. CBCT is used
primarily to evaluate bony anatomy and to screen for
overt pathology of the maxillary sinuses prior to dental
implant treatment [24, 25]. However, prior to any
radiographic imaging, especially for young patients, its
benefit must be to weigh against its risk, with highest
attention to the ALARA principle (as low as reasonably achievable) [8]. This study indicates that panoramic radiography provides a sufficient view of the
maxillary sinus for basic diagnostics, and it may be an
adequate imaging method especially in the initial diagnostic phase. A precise assessment of different conditions of the maxillary sinus may only be possible using
CBCT.

Conclusions
The results of this study emphasize that panoramic radiography visualizes relevant findings of the maxillary
sinus. In comparison to panoramic radiography, CBCT
facilitates diagnosis of special conditions like penetrating
cysts. The inter-observer comparison on panoramic radiographs demonstrated that basal septa were significantly often rated differently, and panoramic imaging
may be based on a rather examiner-dependent assessment. Supplementary, the detection of maxillary bone
cysts penetrating into the sinus with panoramic radiography showed a significant lack in reliability in the intraobserver comparison. Therefore, precise preoperative
evaluation of the maxillary sinus on panoramic radiographs may be difficult. This could be relevant for consecutive surgical procedures; however, higher radiation
dose and costs of three-dimensional imaging need to be
considered.
Competing interest
Johann Malina-Altzinger, Georg Damerau, Klaus W. Grtz and Bernd
Stadlinger declare that they have no competing interests.

Page 6 of 7

Authors contributions
JMA selected the patients, performed the statistical analysis in conjunction
with the institute of statistics, and drafted the manuscript. GD participated in
the evaluation of CBCT and in the design of the study. KWG helped to
conceive and coordinate the study and edited the manuscript. BS conceived
and coordinated the study and helped to draft and edit the manuscript. All
authors read and approved the final manuscript.
Acknowledgements
We would like to thank Dominique Bichsel, Martin Bigler, Johanna Jauernik,
Margrit Roos, Silvio Valdec, and Marius Wolf for their help.
Author details
1
Clinic of Cranio-Maxillofacial Surgery, University Hospital of Bern,
Freiburgstrasse 4, 3010 Bern, Switzerland. 2Clinic of Oral Surgery, Center
of Dental Medicine, University of Zurich, Plattenstrasse 11, 8032 Zurich,
Switzerland. 3Former Head of the Department of Cranio-Maxillofacial and
Oral Surgery, University of Zurich, Plattenstrasse 11, 8032 Zurich, Switzerland.
Received: 19 December 2014 Accepted: 20 May 2015

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